Application
In order to apply, click below and download and print the Application for Coverage.
- Read all questions carefully and answer all questions completely.
- DO NOT complete Page 5, unless you are eligible for immediate coverage. If you complete Page 5, you must include the Required Documentation.
- Be sure to sign and date appropriate pages of application and have your signature witnessed by a third party.
- Include Proof of Residency and a voided check.
- Mail application to Mississippi Comprehensive Health. The address is shown at the bottom of Page 6 of the Application for Coverage.
- DO NOT attempt to send application via email, as this is not a secure web site.
Click here to download the Application for Coverage.